gynecology00 highlights manuel penalver

USMLE Step 2 — Lesson 1: Gynecological Cancers: Part I

Gynecology

Gynecology Highlights for the USMLE Step 2

Manuel Penalver, MD

Cancer Etiology Symp Hist Mort Screen

Cervical HPV Postcoital

Bleeding SCC

AdenocarcUremia PAP

Endometrial Estrogen Postmenop

Bleeding Adenocarc Mets

Ovarian Ovulation Abd dist

Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction

Vulvar HPV Pruritis SCC

MelanomaMets

Tubular Unknown Clear &

serous

DC Adenocarc Mets

Vaginal HPV Bloody DC SCC Mets



Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction

Vulvar HPV Pruritis SCC Mets

Melanoma


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP



Ovarian Ovulation

Abd dist

Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction

Vulvar HPV Pruritis SCC Mets

Melanoma


serous

DC Adenocarc Mets


USMLE Step 2 — Lesson 2: Gynecological Cancers: Part 2



Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP



Ovarian Ovulation Abd dist Epithelial Bowel

Ascites Germ cell

SC Stromal

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP



Ovarian Ovulation Abd dist Epithelial Bowel

Ascites Germ cell

SC Stromal

Obstruction


MelanomaMets


serous

DC Adenocarc Mets


USMLE Step 2 — Lesson 3: Gynecological Cancers: Part 3



Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets




Bleeding SCC

AdenocarcUremia PAP




Ascites

Epithelial

Germ cell

SC Stromal

Bowel

Obstruction


MelanomaMets


serous

DC Adenocarc Mets


Cervical Cancer

Etiology – HPV:

• 70 subtypes

• May lead to genital warts, which may lead to condyloma acuminata

• Can cause pre-cancer (dysplasia or carcinoma in situ)

• Can cause ectocervical cancer

Colposcopy:

• Performed on abnormal Pap smears

• Magnifies 10-12 times

• Acetic acid used for better visualization

• (Cryo, laser, or LEEP (Loop Electro cervical Excision Procedure)

Gestational Trophoblastic Disease

Hydatidiform Mole: Suspect hydatidiform mole if:

o Uterus is bigger (as mentioned above)

o Elevated HCG

o Vaginal bleeding

o Hypertension (early in pregnancy <20 weeks).

Treatment:

• Pre-cancer

o Cryosurgery

o Laser surgery

o LEEP

• True cancer

o Early: Hysterectomy + Para-aortic lymphadenectomy

o Late: Chemotherapy (cysplatinum) & radiotherapy

Indication for cone biopsy:

• Positive ECC

• Unsatisfactory colposcopy (mosaicism that goes inside)

• Two-step discrepancy between cytology and histology

• Microinvasive cervical cancer: cone only way to diagnose

Colposcopy:

• Performed on abnormal Pap smears

• Magnifies 10-12 times

• Acetic acid used for better visualization

• (Cryo, laser, or LEEP (Loop Electro cervical Excision Procedure)

Treatment:

• Pre-cancer

o Cryosurgery

o Laser surgery

o LEEP

• True cancer

o Early: Hysterectomy + Para-aortic lymphadenectomy

o Late: Chemotherapy (cysplatinum) & radiotherapy

Indication for cone biopsy:

• Positive ECC

• Unsatisfactory colposcopy (mosaicism that goes inside)

• Two-step discrepancy between cytology and histology

• Microinvasive cervical cancer: cone only way to diagnose

Cervical intraepithelial neoplasm (CIN) Classification:

CIN I: Mild dysplasia CIN II: Moderate dysplasia CIN III: Severe dysplasia/Carcinoma in situ

Endometrial Cancer

• Etiology:

o Estrogen

• Symptom:

o Post-menopausal bleeding

• Histology:

o Adenocarcinoma

Endometrial Cancer

• Diagnosis:

o Done by endometrial sampling (curettage & histologic exam)

o Endometrial hyperplasia suggests premalignant lesion

USMLE Step 2 — Lesson 4: Gestational Trophoblastic DiseaseGestational Trophoblastic Disease

Hydatidiform Mole: Suspect hydatidiform mole if:

o Uterus is bigger (as mentioned above)

o Elevated HCG

o Vaginal bleeding

o Hypertension (early in pregnancy <20 weeks).

USMLE Step 2 — Lesson 5: Abnormal Vaginal Bleeding: Part 1Abnormal Vaginal Bleeding

• Postmenopausal

• Reproductive Age

• Premenarchal

Premenarchal Bleeding

• Foreign body

• Trauma

• Sarcoma botryoides

• Precocious puberty

Reproductive Age Abnormal Bleeding

• Pregnancy

• Anatomy

• DUB

USMLE Step 2 — Lesson 6: Abnormal Vaginal Bleeding: Part 2Reproductive Age Abnormal Bleeding

• Pregnancy

• Anatomy

• DUB

USMLE Step 2 — Lesson 7: Adnexal Masses Adnexal Masses

• Postmenopausal

• Reproductive Age

• Premenarchal

Clinical Case # 1

65-year-old woman presents with enlarged ovary (6-7 cm)

• First: Confirm presence of mass with ultrasound

• Second: Surgical excision r/o carcinoma

Clinical Case # 2

10-year-old girl presents with adnexal mass

• First: Confirm presence of mass with ultrasound

• Completely abnormal - consider neoplasm

Summary

• Reproductive age adnexal masses - leave it alone

• Premenarchal or postmenopausal adnexal masses - consider neoplasms

Clinical Case # 3

33-year-old woman presents with adnexal mass (6-7 cm) Confirm presence of mass with ultrasound

• - Simple - physiologic cyst - f/u 2 months

• - Complex - dermoid cyst - surgical excision

Clinical Case # 4

An otherwise healthy 33-year-old woman suddenly develops severe lower abdominal pain. An adnexal mass is found on examination

Characteristic - Ovarian torsion

Treatment - Untwist ovary

Clinical Case # 5

33-year-old woman presents with adnexal mass. Her last menstrual period was 6 weeks ago. She also notes lower

abdominal pain and vaginal spotting

Characteristic - Ectopic pregnancy

Ectopic Pregnancy

EP triad: 1: Amenorrhea

2: Lower abdominal pain

3: Vaginal spotting

Clinical Case # 6

33-year-old woman presents with adnexal mass, dysmenorrhea, dyspareunia, and infertility

Characteristic - Endometriosis

Endometriosis

• Adnexal mass in reproductive age group

• Endometrium in ovary / cul de sac

• Triad

1-Dysmenorrhea

2-Dyspareunia

3-Infertility

• Diagnosis by laparoscopy

Endometriosis

Treatment:

o GnRH analogue such as leuprolide (Lupron)

o Birth control pills

o Provera

o Danazol (Danocrine)

• Unsuccessful medical treatment - surgery

Clinical Case # 7

33-year-old woman presents with adnexal mass, lower abdominal pain, fever, and leukocytosis

Characteristic - Tubo-ovarian abscess

Acute PID

• History: Lower abdominal pain & fever 7-10 days after menses, no adnexal mass

• PE: Cervicitis and salpingitis

• Organisms: Gonococcus and Chlamydiae

• Tx: Cephalosporin then oral tetracycline

Chronic PID

• History: acute symptoms + adnexal mass

• Organisms: aerobes & anaerobes-vaginal flora

• Tx: Ampicillin, gentamicin, metronidazol, clindamycin - 72 hr

Reproductive Age

• Physiologic cyst

• Dermoid cyst

• Ovarian torsion

• Ectopic pregnancy

• Endometrioma

• Tubo-ovarian abscess

• Ovarian cancer

USMLE Step 2 — Lesson 8: Vaginitis

Vaginitis Spec Exam Microscopic pH Treatment

Candida Sticky Hyphae (normal)

Antifungal

Haemophilus Whiff test Clue cells (Flagyl)

Metronidazole

Trichomonas Frothy Flagellated

Organisms

(Flagyl)Metronidazole



Antifungal


Metronidazole


Organisms




Antifungal


Metronidazole


Organisms




Antifungal

Haemophilus Whiff test Clue cells Metronidazole

(Flagyl)


Organisms




Antifungal


Metronidazole


Organisms


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